An early decision of transjugular intrahepatic portosystemic shunt may be considered for non-malignant and non-cirrhotic portal vein thrombosis with ascites: a concise review of the theoretical possibility and practical difficulty

An early decision of transjugular intrahepatic portosystemic shunt may be considered for non-malignant and non-cirrhotic portal vein thrombosis with ascites: a concise review of the theoretical possibility and practical difficulty Portal vein thrombosis (PVT) is rarely encountered in the absence of abdominal malignancy or cirrhosis [1]. At the acute stage of PVT, most patients present with abdominal pain of sudden onset or persistently progressing during a short-term period [1]. Provided that the thrombus is extended into the mesenteric venous arch, intestinal ischemia and in-farction can occur [2]. Under the circumstances, appropriate treatments should be timely given. Otherwise, an emergency surgical resection of the bowel is inevitable for intestinal infarction. Once multiple organ dysfunc-tion or failure is complicated in these patients, in-hospital mortality approaches approximately 50% [3]. In the absence of portal recanalization, cavernous collateral vessels develop around the obstructed segment of the portal vein [4]. In the stage of cavernous transformation of the portal vein (CTPV), the most common clinical presentation is variceal bleeding, which can often be tolerated because of well-preserved liver function. Ascites and biliary symptoms are also seen in a minority of patients. Given the high rate of portal vein recanalization and the low incidence of major complications previously reported in several case series [5, 6], the current American Association for the Study of Liver Diseases (AASLD) practice guidelines recommend that anticoagulation therapy for at least 3 months should be initiated just after the diagnosis of acute PVT is established [7]. However, a prospective, multi-center, cohort study showed a relatively low recanalization rate of 38% in patients with acute PVT receiving the immediate use of anticoagulation [8]. More importantly, a significantly inverse correlation between portal vein recanalization and the presence of ascites in the study suggests that alternative therapeutic options should be actively explored. Additionally, the presence of ascites is closely associated with increased mortality in non-malignant and non-cirrhotic patients with PVT [9, 10]. The prognostic value of ascites is further validated by a recent study indicating that the presence of ascites at diagnosis of PVT is the only independent predictor of survival (hazard ratio (HR) = 5.1, p = 0.03), and the cumulative 5-and 10-year survival rates are significantly lower in patients with ascites than those without (83% and 42% vs. 95% and 87%) [11]. Our retrospective case series also demonstrated that the presence of ascites is an independent predictor of death in non-malignant